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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
..�— .
� FOR DEDUCTION FROM ASSESSED VALUATION
• Sfata Fwm 0.1709 (R11 / 6-09)
S � Presm'hetl M DeOMment of Loral Govemment Firerze
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INSTRUCTIONS:
To be filed in person or by ma�7 with fhe CowrtyAWi[w or Counry Recorder of the pounty where the pioperty is bcated. D C
Fdirg Dates: 7) Real Property: Must file durinq the yrear (or whicA tha deduction is sought.
2) MabAe / Manufacfured Homes rrot assessed as Real P/operty: Must h7e during the fwelve (72) months
befo�a March 31 of each year the deduction is s�ughG "��
See reverse side lof additional instnxtnons and qualificafions. _
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M11ard� 1. ament year �Y as of Mortpage /��`traG� tedrress unPaid as at ��9 �9 P�
Mard� 1
If m, wfiat Is his / her e�G share ol interesi? tf awned wi� samearie othc Cw
If name an rcm�d a dtlfereni Nan that ol app6rart4 trMi�ate Cebw.
of mwtgagee or contraa seller (num6er end sbee; crty, state, arW ZIP code)
Name at assi9nee or other owner or hdder of morigage
AGCmss ot assig�e (number aM avee4 �Y. sfefe, and LP code)
Does a
munty
anyi
Yes
Ordu�tion app�wed'u� tlm amount of.
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a-3-
Recorder
: wpaid as d LS the aPP��I Me sde
legal ar equita6le ameR
❑ Yes ❑ No
trWicatewitl�wt�n -
� woo�+v m a�essm: a,�,�ny wzse�a
Rea� Propenr � ?mivalN Assessed
� o �Ac
c� llr����er NO....°�/.(�� �.......
sted on P�Y
Yes ❑ No
20 _ 20 _ I 20 . /
20 _
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1 I We certfy under the penatty of pe�ury that the above arM foregoing infortnation is true and corteU arW that Ne appiiqnt is a resident of Ind�ana and
owner I contrad buyer of the aforementioned property on date applicatlon is filed.
re(o efs fWl neme) � Date (rtwdh. dar Vear1
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FWI miden[ a0drass o1 appOrent (numDer an0 stree4 dTy, state, a+nd LP oode)
� �. ( � , �a �' � Sz; Sa ,�.«�r� � ( l
Pelson author'¢ed by euly erzecuted Power orAimmey w q Ic G7.7-iz-0.7
author'¢ed person (numberand sbaeG dry, sfate, aiM LP mtle)
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